Citation Nr: 9913561
Decision Date: 05/18/99 Archive Date: 05/26/99
DOCKET NO. 95-06 599 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in St.
Petersburg, Florida
THE ISSUES
1. Entitlement to service connection for drug-induced lupus
(secondary to overdose of Atabrine(r)).
2. Entitlement to service connection for cardiovascular
disease, claimed as secondary to the drug-induced lupus.
3. Entitlement to service connection for diabetes mellitus,
claimed as secondary to the drug-induced lupus.
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
Christopher P. Kissel, Counsel
INTRODUCTION
The appellant is a veteran of World War II; he served on
active duty from January 1944 to April 1946.
This case comes before the Board of Veterans' Appeals (the
Board) on appeal from a September 1993 rating decision of the
St. Petersburg, Florida, Department of Veterans Affairs (VA)
Regional Office (RO). The Board remanded this case in
September 1996 for additional development.
FINDINGS OF FACT
1. The appellant served in the Far East Theater of
Operations during World War II and during such service he
ingested Atabrine(r) (quinacrine) to prevent malaria.
2. Service medical records are partially incomplete, but his
separation examination of April 1946 is negative for any
abnormal findings related to Atabrine(r).
3. The medical records which post date service indicate that
he was diagnosed with discoid lupus many years after service,
in 1978 or 1979, by skin biopsy. A 1990 hospital report
noted that the appellant had a history for discoid lupus for
the past ten years.
4. The medical evidence reflects in unequivocal terms that
the appellant has discoid lupus rather than systemic or drug-
induced lupus.
5. VA examiners specializing in dermatology, rheumatology
and infectious diseases who examined the appellant in 1996
and 1998 agreed that it was not likely that he developed
lupus as a result of ingesting Atabrine(r) during service.
These opinions were supported by current laboratory test
results as well as available medical literature addressing
the topic.
6. The appellant does not have drug-induced lupus;
therefore, he has no basis to support his theory of
entitlement to service connection on a secondary basis for
either coronary artery disease or diabetes mellitus.
CONCLUSIONS OF LAW
1. Drug-induced lupus claimed as secondary to overdose of
Atabrine(r) was not incurred in service. 38 U.S.C.A. § 1110
(West 1991); 38 C.F.R. § 3.303(d) (1998).
2. Service connection on a secondary basis for coronary
artery disease or diabetes mellitus is not warranted. 38
C.F.R. § 3.310 (1998).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
I. Background
The appellant contends that he has drug-induced lupus
secondary to his ingestion of Atabrine(r) (quinacrine), an
antimalarial medication, during his World War II military
service in the Philippines and New Guinea. He also contends
that his heart disease and diabetes mellitus were caused by
drug-induced lupus. On file are numerous personal statements
submitted by the appellant which provide cogent recitation of
his contentions. In addition, he has submitted copies of
medical journals and toxicology studies in support of his
claim. Service department records in the file confirm that
he served in the Far East Theater of Operations during World
War II. However, his separation examination of April 1946 is
negative for any abnormal findings related to Atabrine(r), and
the medical records which post date service indicate that he
was diagnosed with discoid lupus many years after service, in
1978 or 1979. Medical records from a Dr. Jaffe, including
the report of a skin biopsy taken in May 1979, reflect the
aforementioned initial post-service diagnosis of discoid
lupus. Additional medical records in the file indicate that
he was hospitalized for a heart attack in 1990 and diagnosed
with coronary artery disease in 1991. The 1990 hospital
report noted that the appellant had a history for discoid
lupus for the past ten years. The records on file also
indicate that he has diabetes mellitus, although it is noted
that he has a family history which is positive for this
disease.
As alluded to above, the Board remanded this case in
September 1996 in response to the appellant's
representative's request that the case be remanded for the
purpose of soliciting a medical opinion pertaining to the
issues on appeal. The requested development was fully
accomplished and will be detailed below.
In November 1996, the appellant was examined on VA
rheumatology and skin (other than scars) examinations. The
rheumatology examination was conducted on November 23, 1996,
and the skin examination on November 24, 1996.
The report of the VA rheumatology examination conducted on
November 23rd did not indicate whether the examiner reviewed
the appellant's claims file, but the following medical
history was reported: The appellant stated that he took
Atabrine(r), an antimalarial medication, for two years during
his World War II-era military service. He did well until
approximately 1976, when he experienced excessive stress in
his life and lost about 25 percent of his body weight.
Shortly thereafter, the appellant stated that he developed a
facial rash and fatigue. He was seen by a dermatologist and
had a skin biopsy which suggested lupus. The appellant told
the VA rheumatologist that he felt Atabrine(r) was responsible
for inducing his lupus because according to the appellant, it
was a fluorinated medication with an extremely long half
life. He further reported by way of medical history that he
had one episode of pleurisy since the original diagnosis of
lupus, but that episode involved pneumonia as well. He
denied any history of nephritis or arthritis, mouth sores,
alopecia, Raynaud's, or clotting. However, the appellant
stated that he was photosensitive.
The appellant's medical history also was reported as
significant for coronary artery disease in 1990, status post
three-vessel bypass in 1991, and a history of diabetes for
the past 7 or 8 years. The appellant stated that he felt his
coronary artery disease was related to his drug-induced lupus
because he had been told in the past that he had a false VDRL
(syphilis test) and therefore, he was concerned about
antiphospholipids. Regarding his diabetes, the appellant
stated that because his lupus could be a systemic disease, it
may have induced his diabetes.
Physical examination findings on the VA rheumatology
examination showed diffuse hyperkeratosis and erythematous
lesions involving the appellant's face, chest and
extremities. However, he had no mouth sores and review of
his neurological and musculoskeletal systems were normal
except for some decreased internal rotation in the right
shoulder. The rheumatologist stated that current laboratory
tests would be needed, but she offered the following
diagnostic assessment based on the aforementioned medical
history and clinical findings:
This gentleman may have lupus. I am
currently unaware of drug inducted lupus
being so prolonged even with fluorinated
hydrocarbons, but I will be checking the
Medline search to see whether this has
ever been reported in the literature.
Drug induced lupus is usually a fairly
benign disease in that i[t] does not
cause end organ damage, such as strokes,
heart attacks or nephritis. Therefore, I
find it extremely unlikely that this
patient's heart attack or diabetes can be
attributed to drug induced lupus. It may
be possible that this gentleman has
acquired primary lupus, which can be
associated with antiphospholipid
syndrome. But again, the pancreas, which
would be responsible for his diabetes is
not an organ that is usually involved in
lupus activity. Therefore, at this time,
we will be sending off multiple labs to
help us distinguish if this gentleman has
primary lupus or a drug induced lupus.
But regardless, I can not feel that at
this time, we can attribute diabetes to
lupus. It is possible that if he has a
primary lupus, he may have an
antiphospholipid syndrome that would be a
good attribute to his coronary artery
disease. I do not have any evidence from
his bypass surgery and he is unaware of
whether there were some pathologic
abnormalities to suggest that he had an
atypical clot, instead of typical
atherosclerosis. To help us further
evaluate the patient, we will be checking
multiple labs to include an admission
profile, CBC, ANA, RPR, ESR, urinalysis,
HATTS profile, antiphospholipids,
anticardiolipids, SSA, SSB, double
stranded and smith antibodies and most
importantly, an antihistamine antibody.
Before the aforementioned laboratory studies could be
completed, the appellant was next examined on the VA skin
examination on November 24, 1996. The report of the
examination noted that the VA dermatologist reviewed the
claims file in conjunction with the examination. The
appellant's medical history was noted to be significant for
the fact that he was given Atabrine(r) (quinacrine)
prophylactically during service to prevent malaria. The
appellant reported that he was on Atabrine(r) for approximately
two years during service, but that he did not experience any
symptoms at that time, or until 1978 when he began suffering
from a rash on his face. He stated that he was diagnosed
with discoid lupus by skin biopsy in 1978. The appellant
could not recall whether he had any additional diagnostic
testing done in 1978, but he added that his skin rash waxed
and waned over the years. He stated that exacerbating
factors included the sun, the heat, the cold, and "air
turbulence." Upon questioning, the appellant stated that he
was somewhat photosensitive, but he denied ever having a
malar rash on his face or oral ulcers. In addition, the
appellant denied having complaints of arthritis of any
joints, a history of pleurisy or pericarditis, a history of
renal disease, seizures or psychotic/neurologic disorders.
Further, the appellant denied having a history of
hematological or immunological abnormalities.
The appellant's medical history reported on the VA skin
examination also was significant for status post myocardial
infarction in 1990, atrial fibrillation in 1990, and
diabetes, diagnosed in 1990.
On physical examination, the appellant had numerous
erythematous scaly well-defined plaques with central scarring
over his dorsal hands, dorsal forearms and outer upper arms.
Much of his face and ears were covered in the plaques as
well. A small amount was seen on his upper mid chest and
upper back. In addition, he had diffuse hyperpigmentation in
these areas and periungual erythema of his finger nails.
Based on the appellant's medical history and the clinical
findings found on examination, the VA dermatologist's
diagnostic impression was discoid lupus that was most likely
not related to the ingestion of the Atabrine(r) medication.
However, the examiner stated that additional laboratory
testing, including the above-cited ANA, anti-double stranded
DNA, CBC, and a skin biopsy, would be required to rule out
discoid lupus versus systemic lupus. The examiner added that
most drug-induced lupus occurred within one to five years of
the onset of the medications and that skin disease associated
with a systemic lupus was much less prevalent in the drug-
induced lupus.
The record reflects that the laboratory studies cited above
were conducted in December 1996. Based on the results of
these tests, the VA rheumatologist prepared an addendum
report to her examination on December 23, 1996, which reads
as follows:
Med-line search from current data back to
1966 shows no mention of Atabrine being
associated w[ith] SLE [systemic lupus
erythematosus]. As a matter of fact, it
has been used to treat SLE. The
[patient's] anti-histone antibodies are
negative, which by definition rules out
drug induced lupus. His negative ANA
virtually rules out the possibility of
SLE. Also he does not have a clinical
[history] to support a [diagnosis] of
SLE. He does not have SLE or drug
induced lupus. He may have a skin lupus,
but I'll defer to derm[atology] for the
[diagnosis].
In response to the RO's denial of his claim by supplemental
statement of the case in June 1997, which was based on the
results of the above-cited VA examinations, the appellant
obtained a statement from S. M. Roberts, Ph.D., an associate
professor and program director at the University of Florida's
Center for Environmental & Human Toxicology. Dr. Roberts'
statement, dated November 10, 1997, indicates that he
reviewed the medical literature for a possible association
between the antimalarial drug Atabrine(r) (quinacrine) and the
development of drug-induced lupus. It was noted by Dr.
Roberts that the appellant's medical history was significant
for his ingestion of quinacrine during World War II and that
in 1976 following an episode of rapid weight loss, he was
diagnosed with "drug-induced lupus." The appellant also
told Dr. Roberts of his belief that fat-stored quinacrine was
released during the weight loss and that such release
precipitated the development of lupus symptoms. Dr. Roberts
went on to discuss that it was a well-known fact that troops
serving in the Pacific Theater during World War II were given
quinacrine to prevent malaria, and that it was known that
some troops contracted an unusual skin disease called
tropical lichen planus. Medical literature disclosed that
this disease was associated with quinacrine treatment. One
source also noted that the disease closely resembled lupus
erythematosus, especially when it involved the bulb of the
nose and the butterfly regions of the face. Another source
in the medical literature noted that atypical lichen planus
produced by quinacrine involved lesions that resembled
psoriasis or lupus erythematosus.
Dr. Roberts went on to state that the body of literature from
the late 1940s was extensive as to the issue of quinacrine
being the causative agent for dermatologic disease, including
symptoms resembling lupus. Little or no information
regarding quinacrine dermatotoxicity was found after the mid-
1950s because less toxic antimalarial drugs were in use after
World War II. Regarding Medline, Dr. Roberts stated that
that system's database only went back to 1966, so it would be
unable to archive any publications regarding quinacrine from
the World War II-era. With respect to the appellant's
condition, Dr. Roberts offered the following commentary:
With regard to the delayed onset of your
symptoms, the solubility characteristics
of quinacrine suggest that it would not
be stored extensively in fat tissue - the
lipid solubility of this drug is low.
However, there is apparently remarkable
sequestration of the drug in other
tissues, with the liver, spleen, lungs,
and adrenal glands reportedly possessing
the highest concentrations. Quinacrine
can accumulate in some tissues to
concentrations 20,000 times that of
plasma levels, and this no doubt
contributes to slow elimination of the
drug. Quinacrine has been detected in
tissues five years after discontinuation
of the drug. We could find no studies
dealing with longer time periods, and it
is difficult to predict how much
quinacrine might remain after 30 years
(as in your case, from 1946 to 1976). It
is possible that physiologic changes
accompanying your weight loss in 1976
could cause the release of residual
quinacrine from relevant storage cites in
the body, but [it is] difficult to
predict precisely what those residual
levels might be.
The RO reviewed Dr. Roberts' statement but again denied the
appellant's claim by supplemental statement of the case in
December 1997 on the basis that the statement did not
correlate the ingestion of Atabrine (r) (quinacrine) with the
onset of discoid lupus, the diagnosis established on the VA
examinations in 1996.
In response to the above, the appellant obtained a statement
from J. D. Parks, M.D., a dermatologist affiliated with the
Parks Dermatology Center, Ormond Beach, Florida. Dr. Parks'
statement, dated November 17, 1997, reads as follows, in
pertinent part:
I am a Dermatologist in private practice
in Ormond Beach, FL but had the pleasure
of treating [the appellant] as a patient
when I was Chief Resident of Dermatology
at the Gainesville VA Medical Center in
1996. . . . Clinical, and by biopsy,
[the appellant's skin disease] is classic
discoid lupus erythematosus which is a
variant of lupus which involves the skin
only. He does not, to my knowledge, have
systemic lupus erythematosus. [The
appellant] has been very diligent in
researching and acquiring literature
relating Quinacrine to the outbreak of
his lupus erythematosus. It is
interesting that as dermatologist's, we
often use Quinacrine to treat lupus. He
had received the Quinacrine as an
antimalarial while in the service in a
Pacific theater of WWII. There have been
reports from that time of servicemen
developing lichen planus which may have
resembled lupus erythematosus but I know
of no reports that it was definitely
lupus erythematosus. It is out of my
field of expertise to comment on whether
the Quinacrine caused his lupus
erythematosus or not. I would say it is
at least possible. Quinacrine is a
serious systemic medication which has
many potential adverse side effects. All
I can say at this time is that the
Quinacrine may have led to a skin disease
though I have no personal experience
other than the literature that [the
appellant] supplied for my review.
Finally, in September 1998, the appellant was examined on a
VA infectious, immune, and nutritional disabilities
examination. Clinically, the appellant had discoid,
atrophic, hypopigmented plaques with scales on his cheek,
malar emesis, chin, forehead, as well as around the back of
the neck and forearm. Based on these findings, his medical
history, and review of the voluminous claims file, the
following diagnosis and medical opinion was made:
Discoid cutaneous lupus. In review of
the medical literature and his file, the
patient has been diagnosed with discoid
lupus in the past in which the
examination today is consistent with
that. The patient's last laboratories
were last done in January of 1997 which
had a negative ANA as well as extended
ANA with negative SSA, SSB, histone and
single-strained DNA as well as [left
blank by transcriber]. This is all
consistent with cutaneous skin lupus not
systemic lupus. In review of his
records, it is also illustrated that the
patient has thoroughly examined the
nature of lupus and describes that he
meets seven of the 11 criteria. It is
very difficult for me to state whether
the patient has systemic lupus in view of
his negative antibody profiles. The
patient reports that he got this from his
quinacrine therapy. I feel that this is
very difficult for me to comment on. The
patient does not to my knowledge have
systemic lupus and [he] has been very
diligent in reviewing the systemic signs
as well as presenting me with some
literature in regard to possible
quinacrine and outbreaks of lupus. We
occasionally use quinacrine in treatment
of lupus which is somewhat ironic. He
reports that he did have the diagnosis of
having lupus after quinacrine. There
have been reports in the past of lichen
planus which can mimic lupus caused by
quinacrine and it is impossible for me to
say if that is what the patient had at
that time. Cutaneous as well as systemic
lupus is very difficult to say what the
etiology is. We have never been able to
figure it out but we do know that
systemic lupus is an autoimmune process
with positivity in autoimmune antibodies
which the patient is lacking. The
patient appears well-nourished and is
doing fine today and I do not think that
he has difficulties with nutritional
deficiency at this time. The patient has
also had a biopsy two years ago which was
consistent with discoid lupus.
To make a definite statement that
quinacrine caused his disease or did not
cause his disease is nearly impossible to
make. The reason it is so difficult is
because the etiology of discoid lupus is
uncertain as well as there is not a lot
in the literature of quinacrine causing
this problem. To my knowledge, I cannot
find anything in the literature stating
that it does cause discoid cutaneous
lupus.
II. Analysis
The Board initially notes that it finds this claim to be well
grounded. 38 U.S.C.A. § 5107(a) (West 1991). It is conceded
that the appellant ingested Atabrine(r) during his World War
II-era military service and that he currently has a skin
condition diagnosed as discoid cutaneous lupus. When this
evidence is considered along with the medical opinion of Dr.
Parks that it was "at least possible" that the appellant's
ingestion of Atabrine(r) could have caused his lupus, the Board
finds that the claim is not inherently implausible. 38
U.S.C.A. § 5107(a) and Murphy v. Derwinski, 1 Vet. App. 78
(1990).
Moreover, the Board is of the opinion that VA has fulfilled
its statutory duty to assist the appellant in developing the
pertinent facts in this case. Exhaustive efforts to develop
this case as ordered by the Board's remand of September 1996
have rendered the record sufficiently complete for appellate
review at this time. See Dusek v. Derwinski, 2 Vet. App. 519
(1992).
A merits-based review of a claim requires the Board to
provide a written statement of the reasons or bases for its
findings and conclusions on material issues of fact and law.
38 U.S.C.A. § 7104(d)(1) (West 1991). To this end, the Board
must analyze the credibility and probative value of the
evidence, account for evidence which it finds to be
persuasive or unpersuasive, and provide reasons for rejecting
any evidence favorable to the veteran. See Masors v.
Derwinski, 2 Vet. App. 181 (1992); Hatlestad v. Derwinski, 1
Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49
(1990).
Moreover, the Board may not base a decision on its own
unsubstantiated medical conclusions but, rather, may reach a
medical conclusion only on the basis of independent medical
evidence in the record or adequate quotation from recognized
medical treatises. See Colvin v. Derwinski, 1 Vet. App. 171
(1991).
Under pertinent law and VA regulations, service connection
may be granted if the facts shown by the evidence, establish
that a disease or injury resulting in disability was incurred
coincident with service in the Armed Forces, or if pre-
existing such service, was aggravated therein. 38 U.S.C.A.
§§ 1110, 1153 (West 1991); 38 C.F.R. §§ 3.303, 3.306 (1998).
For veterans who served on active duty for 90 days or more
during a war period or after December 31, 1946, service
connection may also be granted for certain enumerated chronic
diseases on a presumptive basis, including systemic lupus
erythematosus, if manifestations related thereto are shown to
be present to a degree of 10 percent or more within one year
after service. 38 U.S.C.A. §§ 1101, 1112 (West 1991); 38
C.F.R. §§ 3.307, 3.309 (1998).
Alternatively, service connection may be granted for any
disease diagnosed after service if all the evidence,
including that pertinent to service, establishes that the
disease was incurred in service. 38 C.F.R. § 3.303(d)
(1998).
Before addressing the underlying merits of the claim, the
Board will first discuss a number of facts that are not in
dispute. (1) It is undisputed that the appellant served in
the Far East Theater of Operations during World War II and
(2) and that he ingested Atabrine(r) during his military
service because it is a well-known fact that servicemen in
that theater of operations were given the medication to
prevent malaria. One more important fact is not in dispute:
The medical evidence as well as the appellant's own
contentions support a finding that he was symptom-free of any
lupus disease until many years after service, specifically,
until the mid-1970s when he first developed a facial rash and
fatigue. As detailed above, the medical records from Dr.
Jaffe indicate that a skin biopsy taken in May 1979 resulted
in a diagnosis of discoid lupus. It also is conceded that
the appellant has coronary artery disease and diabetes
mellitus.
Hence, although the file reflects that some of the
appellant's service records were destroyed in the 1973 fire
at the National Personnel Records Center, this case is not a
true "lost-records case" as that term is defined by
judicial precedent because a factual issue from the
appellant's military service is not germane to the
disposition of this appeal. This is, instead, a case that
turns on establishing service connection via 38 C.F.R.
§ 3.303(d), as the appellant has a disease that he admits had
its onset many years after service, as shown by the medical
evidence, but which he believes was caused by medication that
he took during service.
After carefully reviewing all of the pertinent evidence
together with the appellant's pleadings and contentions of
record, the Board concludes that a preponderance of the
evidence is against the claim of entitlement to service
connection for drug-induced lupus, claimed as secondary to
ingestion of Atabrine(r). As indicated above, comprehensive
clinical evaluations of the appellant's skin disease do not
support a diagnosis of drug-induced lupus. The medical
evidence reflects in unequivocal terms that the appellant has
discoid lupus rather than systemic or drug-induced lupus. A
diagnosis of discoid lupus is consistently shown by the
medical evidence beginning with the initial diagnosis of the
appellant's lupus disease by Dr. Jaffe in 1979, and
continuing through to the present, as reported by the VA
dermatologist in November 1996, by the VA rheumatologist in
December 1996, by Dr. Parks in November 1997, and again by
the VA infectious disease specialist in September 1998.
There is no other medical evidence in this case which rebuts
the diagnosis of discoid lupus established by the
aforementioned examiners.
Moreover, a preponderance of the evidence is against the
appellant's underlying theory of entitlement, i.e., the
Atabrine(r) he ingested during his World War II-era military
service caused him to develop a lupus disease many years
later. All of the above-cited VA examiners who examined the
appellant in 1996 and 1998 agreed that it was not likely that
he developed lupus as a result of ingesting Atabrine(r) during
service. The VA dermatologist in November 1996 reviewed the
evidence then of record and concluded that the appellant's
discoid lupus was most likely not related to ingestion of
Atabrine(r). He stated that most drug-induced lupus occurred
within 1 to 5 years of the onset of the medication use. This
finding is supported by Dr. Roberts' medical literature
review findings reported in his November 1997 statement.
Moreover, the VA rheumatologist concluded in December 1996
that based on his laboratory test results, the appellant did
not have a clinical picture consistent with systemic or drug-
induced lupus. Finally, in December 1998, the VA infectious
disease specialist reviewed all of the evidence of record and
concluded that although the etiology of the appellant's
discoid lupus was difficult to ascertain, he could find no
literature to support a finding that ingestion of Atabrine(r)
could cause discoid cutaneous lupus. This finding is
supported by Dr. Parks' statement of November 1997 where he
stated that he was aware of reports that servicemen developed
lichen planus after taking quinacrine (Atabrine(r)) during
World War II, but that he did not know of any reports
identifying the condition as lupus erythematosus.
Hence, when all of these findings and medical opinions are
read together, the Board finds that Dr. Parks' statement that
it was at "least possible" that the appellant's lupus was
caused by the ingestion of quinacrine is outweighed by the
balance of the evidence. First of all, Dr. Parks' couched
his statement by disclaiming specific expertise as to the
possible connection between quinacrine and lupus. Secondly,
however, and more importantly, when read together with the
medical findings in this case, the balance of Dr. Parks'
statement makes clear that the kind of lupus the appellant
has not been shown to have association with quinacrine use.
As noted above, all of the examiners have agreed that the
appellant's condition is discoid rather than drug-induced
lupus. And, it is clear from the record in this case that
there is no support in the medical literature for the theory
that quinacrine ingestion by servicemen in World War II
caused lupus erythematosus. Dr. Parks' statement
acknowledges this fact. Accordingly, when his statement is
considered along with the specific facts in this case, it
does not actually support the appellant's theory of
entitlement to service connection.
The appellant's contentions advanced on appeal, including his
hearing testimony of May 1995, without clinical
corroboration, are considered to be of insufficient probative
value to serve as a basis for a grant of service connection
because the issue in dispute is a matter requiring medical
knowledge. See Espiritu v. Derwinski, 2 Vet. App. 492
(1992). The record reflects that the appellant has training
in chemistry, however, it is not shown that he possesses the
requisite medical expertise to address the underlying issues
in this case. The same can be said for the medical journal
articles/textbook entries submitted by the appellant in
support of his claim. While these materials are generally
relevant to the claim, they are of insufficient probative
value to the disposition of this case compared to the medical
examination findings and opinions detailed above, all of
which are specific to the facts in this case.
Moreover, to the extent that the appellant has proffered
statements regarding what medical professionals may have told
him in the past concerning the etiology of his lupus disease,
such statements also are of insufficient probative value to
outweigh the balance of the evidence which is against the
claim. If hearsay evidence is generally regarded as
insufficient to render a claim well grounded, the Board is
certain that such evidence is of equally insufficient value
in a merits-based analysis of a claim. See e.g. Robinette v.
Brown, 8 Vet. App. 69 (1995) (hearsay medical evidence,
transmitted by a layperson, cannot be sufficient to render a
claim well grounded; connection between what a physician said
and a layperson's account of what that physician purportedly
said is simply too attenuated and inherently unreliable to
constitute medical evidence).
For the reasons discussed above, the preponderance of the
evidence found probative to the issue on appeal weighs
against a grant of the benefits sought; the benefit of the
doubt is for application where the evidence is found to be
relatively evenly balanced. 38 U.S.C.A. § 5107(b) (West
1991); 38 C.F.R. § 3.102 (1998).
As the appellant's claims for coronary artery disease and
diabetes mellitus are derivative of the claim of service
connection for drug-induced lupus, i.e., they are predicated
on establishing service connection for the latter condition,
are denied as well. See 38 C.F.R. § 3.310 (1998).
ORDER
Service connection for drug-induced lupus is denied.
Service connection for coronary artery disease claimed as
secondary to drug-induced lupus is denied.
Service connection for diabetes mellitus claimed as secondary
to drug-induced lupus is denied.
A. BRYANT
Member, Board of Veterans' Appeals